Summary Vision Screening Data: Slovakia

Produced as part of Work Package 3

Paolo Mazzone1, Dr Jill Carlton2, Dr Helen Griffiths3

1. Research Assistant, School of Health and Related Research, University of Sheffield, United Kingdom (UK)

2. Senior Research Fellow, School of Health and Related Research, University of Sheffield, United Kingdom

(UK)

3. Senior Lecturer, Academic Unit of Ophthalmology and Orthoptics, University of Sheffield, United Kingdom

(UK)

Information provided by Dr Alena Furdova, Ophthalmologist, Comenius University in

Bratislava) & Dr Dana Tomcikova, Ophthalmologist, Comenius University in Bratislava

21st December 2018

Disclaimer: This is a summary report representing the responses from a country representative working within

eye care services of the country reported. This report does not represent conclusions made by the authors,

and is the product of professional research conducted for the EUSCREEN study. It is not meant to represent

the position or opinions of the EUSCREEN study or its Partners. The information cannot be fully verified by the

authors and represent only the information supplied by the country representatives.

This project has received funding from the European Union’s Horizon 2020 research

and innovation programme under Grant Agreement No 733352

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Contents

1 Glossary of Terms: Vision Screening iii

2 Abbreviations vi

3 Population and Healthcare Overview 1

4 Vision Screening Commissioning and Guidance 3

5 Screening programme 4

5.1 Vision screening - Preterm babies 4

5.2 Vision screening - Birth to 3 months 4

5.3 Vision screening - 3 months to 36 months 4

5.4 Vision screening - 36 months to 7 years 4

6 Automated Screening 9

7 Provision for Visually Impaired 10

8 Knowledge of existing screening programme 11

8.1 Prevalence/Diagnosis 11

8.2 Coverage 11

8.3 Screening evaluation 11

8.4 Treatment success 11

9 Costs of vision screening in children 12

9.1 Cost of vision screening 12

9.2 Cost of treatment for amblyopia 12

9.3 Cost of Treatment for strabismus 12

9.4 Cost of treatment for cataract 12

10 References 13

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1 Glossary of Terms: Vision Screening

Abnormal test result A test result where a normal “pass” response could not be

detected under good conditions. The result on screening

equipment may indicate “no response,” “fail,” or “refer.”

Attendance rate The proportion of all those invited for screening that are tested

and receive a result:

Invited for screening includes all those that are offered

the screening test.

Tested and receive a result could be a “pass” or “referral

to diagnostic assessment”.

Attendance rate provides information on the willingness of

families to participate in screening.

Compliance with

referral (percentage)

The percentage of those who are referred from screening to a

diagnostic assessment that actually attend the diagnostic

assessment.

Percentage of compliance provides information on the

willingness of families to attend the diagnostic assessment after

referral from screening.

Coverage The proportion of those eligible for screening that are tested and

receive a result:

Eligible for screening includes those within the population

that are covered under the screening or health care

programme.

Tested and receive a result could be a “pass” or “refer to

diagnostic assessment”.

Factors such as being offered screening, willingness to

participate, missed screening, ability to complete the screen, and

ability to document the screening results will influence the

coverage.

False negatives The percentage of children with a visual deficit (defined by the

target condition) that receive a result of “pass” during screening.

Example: If 100 children with visual deficit are screened, and 1

child passes the screening, the percentage of false negatives is

1%.

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False positives The percentage of children with normal vision that are referred

from screening to a diagnostic assessment.

Guidelines Recommendations or instructions provided by an authoritative

body on the practice of screening in the country or region.

Vision screening

professional

A person qualified to perform vision screening, according to the

practice in the country or region.

Inconclusive test

result

A test result where a normal “pass” response could not be

detected due to poor test conditions or poor cooperation of the

child.

Invited for screening Infants/children and their families who are offered screening.

Outcome of vision

screening

An indication of the effectiveness or performance of screening,

such as a measurement of coverage rate, referral rate, number of

children detected, etc.

Untreated amblyopia Those children who have not received treatment for amblyopia

due to missed screening or missed follow-up appointment.

Persistent amblyopia Amblyopia that is missed by screening, or present after the child

has received treatment.

Positive predictive

value

The percentage of children referred from screening who have a

confirmed vision loss.

For example, if 100 babies are referred from screening for

diagnostic assessment and 10 have normal vision and 90 have a

confirmed visual defect, the positive predictive value would be

90%.

Prevalence The percentage or number of individuals with a specific disease

or condition. Prevalence can either be expressed as a percentage

or as a number out of 1000 individuals within the same

demographic.

Programme An organised system for screening, which could be based

nationally, regionally or locally.

Protocol Documented procedure or sequence for screening, which could

include which tests are performed, when tests are performed,

procedures for passing and referring, and so forth.

Quality assurance A method for checking and ensuring that screening is functioning

adequately and meeting set goals and benchmarks.

Referral criteria A pre-determined cut-off boundary for when a child should be

re-tested or seen for a diagnostic assessment.

Risk babies / Babies

at-risk

All infants that are considered to be at-risk or have risk-factors

for vision defects/ophthalmic pathology according to the

screening programme.

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Two common risk factors are admission to the neonatal-intensive

care unit (NICU) or born prematurely. However, other risk factors

for visual defects may also be indicated in the screening

programme.

Sensitivity The percentage of children with visual defects that are identified

via the screening programme.

For example, if 100 babies with visual defects are tested, and 98

of these babies are referred for diagnostic assessment and 2 pass

the screening, the sensitivity is 98%.

Specificity The percentage of children with normal vision that pass the

screening.

For example, if 100 babies with normal vision are tested, and 10

of these babies are referred for diagnostic assessment and 90

pass the screening, the specificity is 90%.

Target condition The visual defect you are aiming to detect via the screening

programme.

Well, healthy babies Infants who are not admitted into the NICU or born prematurely

(born after a gestation period of less than 37 weeks).

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2 Abbreviations

GDP Gross Domestic Product

NICU Neonatal-intensive care unit

PPP Purchasing Power Parity

ROP Retinopathy of Prematurity

VA Visual Acuity

WHO World Health Organisation

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3 Population and Healthcare Overview

The population of Slovakia is 5,439,892 (World Bank, 2018a) and birth rate estimated at 10.6

births/1,000 population in 2016 (World Bank, 2018b). The change in population and birth

rate from 1960 to 2017 is shown in Figure 1, graphs A and B respectively.

Slovakia has a reported population density of 113 people per square kilometre in 2017 and

this has risen from 87 people per square kilometre in 1961 (World Bank, 2018c). In terms of

healthcare facilities, the total density of hospitals in 2013 was 1.54 per 100,000 population

(WHO, 2016a). Infant mortality in 2017 is estimated at 4.6 deaths/1,000 live births in total

(World Bank, 2018d).

The average life expectancy in Slovakia is estimated at 76.6 years (World Bank, 2018e), with

a death rate of 9.6 deaths/1,000 population in 2016 (World Bank, 2018f). Slovakia has a gross

national income per capita (PPP int. $, 2013) of $25,000 (WHO, 2016b). The estimated total

expenditure on health per capita in 2014 was $2,179 (Intl $) and the total expenditure on

health in 2014 as percentage of GDP was 8.1% (WHO, 2016b).

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Figure 1: Change in the Total Population and Birth Rate in Slovakia between 1960 and 2017

Source: Information sourced from World Bank (2018)

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4 Vision Screening Commissioning and Guidance

In Slovakia, vision screening is funded through health insurance. The vision screening

programme is organised nationally, with no regional variations in protocols. Vision screening

is embedded in a general preventative child health care screening system and is performed

by paediatricians, ophthalmologists and healthcare support workers within child healthcare

centres and hospitals. In Slovakia, there are 1,642 paediatricians and approximately 500

registered ophthalmologists, however it is not known exactly how many of them perform

vision screening. No other healthcare professionals have been identified that could screen

with additional training. There is no specific training to perform vision screening, instead, this

is part of postgraduate education in paediatrics.

The content of the vision screening programme is decided upon by the government and there

have been changes made. Currently the vision screening programme for refractive errors and

amblyopia is completed between the ages of 3 years and 5 years. The method used by

paediatricians, is reading and pictures. The new proposal is to conduct the screening in all

children at the age of 3 years using Cardiff or Lea Symbols, combined with cover/uncover test

and PlusOptix screening, which should be done in the kindergarten by a qualified nurse. The

proposal is not accepted yet, and the tests are currently only completed by paediatric

physician.

There are no guidelines for vision screening and there is no protocol for timing of programme

revision. Changes are not made on regular basis, they are made when a group of experts make

an appeal and it is approved by the Healthcare Ministry. Such revisions are conducted by the

Ministry of Health, who also provide funding for such endeavours.

There are no methods for quality monitoring imposed by the government and there has been

no research concerning the vision screening programme in Slovakia. There has been no cost-

effectiveness analysis and no other studies on the effectiveness of vision screening in

Slovakia.

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5 Screening programme

In Slovakia, retinopathy of prematurity (ROP), congenital eye disorders and amblyopia are

the target conditions of vision screening. The health care professionals delivering vision

screening, venue for screening and tests used vary depending on the age of the child as shown

in Tables 1, 2 and 3 respectively. Specific details of the screening offered within each age

group are described more fully in sections 5.1 to 5.4 below.

5.1 Vision screening - Preterm babies

Preterm babies up to the age of 3 months are screened in hospitals using eye inspection,

fixation, red reflex testing, retinal examination, eye motility, pursuit movements and pupillary

reflexes. These tests are performed in part by a paediatrician and also by an ophthalmologist

who screens for ROP in all children born before 32 weeks and those who weigh less than 1200

grams. Other babies are evaluated if there are risk factors for ROP. The ophthalmologist will

conduct a cataract screening in premature babies at the same time ROP screening is

conducted. Preterm babies with or without ROP undergo ophthalmological evaluation until

the vascularisation is completed. The parents are then informed about the timing of any

subsequent examinations, dependent upon the findings.

5.2 Vision screening - Birth to 3 months

Well, healthy babies up to the age of 3 months are screened in either a hospital or a child

health centre using eye inspection and red reflex testing (5 days to 4 weeks postnatal), fixation

and eye motility (at 3 months). The vision screening, including red reflex testing to diagnose

a white pupil, is conducted by either a paediatrician or an ophthalmologist. Babies are

referred to the ophthalmologist when the paediatrician notices strabismus, an abnormality in

anatomical appearance of the eye, and/or when there is an abnormal reaction to a visual

stimulus. Babies are referred for further examination after one or two abnormal or

inconclusive tests at the doctor’s discretion.

5.3 Vision screening - 3 months to 36 months

At 12 months of age, children are screened using eye inspection, fixation and eye motility.

This is conducted by a paediatrician at a child health centre and repeated at 36 months of

age. Children are referred to the ophthalmologist when the paediatrician notices strabismus,

an abnormality in anatomical appearance of the eye, and/or when there is an abnormal

reaction to a visual stimulus. Babies are referred for further examination after one or two

abnormal or inconclusive tests, at the doctor’s discretion. .

5.4 Vision screening - 36 months to 7 years

Between the ages of 36 months to 7 years, children are screened at the age of 5 years and

again at 6 to 7 years of age. At the age of 5, vision screening is conducted at child health

Summary Vision Screening Data: Slovakia

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centres by paediatricians, using eye inspection, fixation, eye motility and a visual acuity (VA)

measurement.

VA is measured for the first time at 5 years of age and it is assessed using E-pfluger (Pfluger

hooks are similar to the letter E in a standardised form and size in all directions) and linear

picture charts, with a range of 1.0 to 0.1 (decimal). Visual acuity is measured for a second time

at either 6 or 7 years of age (dependent on the child availability) by a paediatrician.

If there is one-line difference in visual acuity at the age of 5 years, then children are referred

to an ophthalmologist for further diagnostic examination. Children are referred to the

ophthalmologist when the paediatrician notices strabismus, an abnormality in anatomical

appearance of the eye, and/or when there is an abnormal reaction to a visual stimulus.

Children are referred for further examination after one or two abnormal or inconclusive tests

at the doctor’s discretion.

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Table 1: Healthcare professionals who conduct vision screening in each age group

Table 1 Paediatrician Ophthalmologist

Preterm babies

0 to 3 months

3 to 36 months

×

3 to 7 years

×

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Table 2: Vision screening tests used in vision screening for each age group

Table 2 Retinal

Exam

Eye

inspection

Red

reflex

Eye

motility

Fixation Retinal

examination

Pursuit

movements

Visual

acuity

Pupillary

reflexes

Preterm babies

×

0 to 3 months ×

× × × ×

3 to 36 months ×

×

× × × ×

3 to 7 years ×

×

× × ×

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Table 3: Location of vision screening for each age group

Table 3 Hospital Child healthcare centre

Preterm babies ×

0 to 3 months

3 to 36 months ×

3 to 7 years ×

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6 Automated Screening

Automated vision screening is achieved using handheld, portable devices designed to detect

presence of refractive error from 6 months of age. It provides objective results and is used to

detect amblyopic risk factors. This differs from other methods used to screen children for

amblyopia which focus on detection of the actual condition and the resulting visual loss.

In Slovakia, PlusOptix automated screening devices are used, however, screening using

PlusOptix is not yet a standarlised screening test. There are some foundations who conduct

the screening tests for free and individual private optic shops who conduct it for business

purposes. There are approximately ten of these devices in Slovakia, but there is no exact

information.

There is no specific age at which these tests are performed, however, it is usually conducted

in kindergarten (4-5 years of age). There are no defined referral criteria, the optic specialists

(not doctors) send everyone that they think needs to be referred. These devices cost

approximately 6000 Euros, with unknown maintenance costs. The devices should be replaced

every 5 years.

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7 Provision for Visually Impaired

In Slovakia, there are approximately 3 schools for blind or severely visually impaired children.

Two schools are elementary, the third school is a high school in which there are also physically

and mentally disabled children. Placing the child in the special school is also dependant on

the mental capacity of the student. The two elementary schools are located in Levoca and

Bratislava. Special school in Levoca has 43 day students and 13 external students. Bratislava

is about the same. The special high school in Levoca has about 40 students and out of that 14

children are studying to become cooks.

The costs per child for these schools is unknown and whilst there is support for visually

impaired children who attend mainstream primary school, it is unknown what this support is.

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8 Knowledge of existing screening programme

8.1 Prevalence/Diagnosis

The prevalence of treated or untreated and persistent amblyopia, by the age of 7 years, is

estimated at 20%. This figure is estimated from the statistics of medical information based on

the statistics of children aged 7-8 years. This is true for all other estimations in section 8. The

prevalence of persistent amblyopia, by age 7 years is not known. The prevalence of strabismus

is estimated at 15% at age 7 years. There is no data provided on the incidence of the four

types of amblyopia (strabismic, refractive, combined-mechanism and deprivation) in Slovakia.

8.2 Coverage

All children are invited for vision screening at the age of 5 years and this invitation is carried

out by a paediatrician by way of a letter. The coverage and subsequent attendance of any

kind of vision screening, before the age of 7 years, is estimated at 99-100%. All children (100%)

are invited and attend a VA measurement as part of vision screening, before the age of 7

years.

8.3 Screening evaluation

The percentage of false positives is estimated at 10%. The percentage of false negatives is

estimated at 10%. The positive predictive value of a refer result, after vision screening, is

estimated at 60%. The sensitivity and the specificity of vision screening is not reported.

8.4 Treatment success

It is estimated that 100 infants are treated for congenital eye disorders, per year, in the total

population. Twenty percent of children are treated for strabismus and amblyopia, after being

screened before 7 years of age. Eighty percent of these children are treated for strabismus by

7 years of age. Ninety percent of these children are treated for amblyopia by 7 years of age.

There is no registration or documentation of noncompliance with referral after an abnormal

screening test result, however, it is estimated that 80% of children comply with a referral after

an abnormal screening test result. It is estimated that 2500 patients are treated, per year, for

congenital cataract, amblyopia and strabismus by ophthalmologists. Ophthalmologists are

the professionals that prescribe glasses for children under the age of 7 years, after referral

from screening. Other treatment options include patching, penalisation with glasses, atropine

and cataract surgery. All eligible children with vision disorders are offered treatment.

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9 Costs of vision screening in children

9.1 Cost of vision screening

The salary costs per year and per hour for vision screening professionals are not available. The

cost of training general preventative child healthcare screening professionals, between

leaving secondary education to qualification, is not available. The total vision screening costs,

per year and per child are not known.

9.2 Cost of treatment for amblyopia

The estimated costs for treatment of typical patients with refractive amblyopia and strabismic

amblyopia are not known.

9.3 Cost of Treatment for strabismus

The estimated cost of strabismus surgery is 1000 Euros; the cost of follow-up is not known.

9.4 Cost of treatment for cataract

The estimated costs for congenital cataract surgery is 1500 Euros. The cost of follow-up

including deprivation amblyopia is not known.

Vision screening is free of charge to parents. Vision screening is obligatory, but it is not strictly

enforced; instead, the responsibility lies with the parent and those who do not bring their

children to screening can lose their governmental child support. There is no financial reward

for those who do attend vision screening.

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10 References

The World Bank (2018a). Population, total | Data. [online] Available at:

https://data.worldbank.org/indicator/SP.POP.TOTL?locations=SK [Accessed 20 December

2018].

The World Bank. (2018b). Birth rate, crude (per 1,000 people) | Data. [online] Available at:

https://data.worldbank.org/indicator/SP.DYN.CBRT.IN?locations=SK [Accessed 20 December

2018].

The World Bank. (2018c). Population density (people per sq. km of land area) | Data. [online]

Available at: https://data.worldbank.org/indicator/EN.POP.DNST?locations=SK [Accessed 20

December 2018].

The World Bank. (2018d). Mortality rate, infant (per 1,000 live births) | Data. [online]

Available at: https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=SK [Accessed

20 December 2018].

The World Bank. (2018e). Life expectancy at birth, total (years) | Data. [online] Available at:

https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=SK [Accessed 20 December

2018].

The World Bank. (2018f). Death rate, crude (per 1,000 people) | Data. [online] Available at:

https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=SK [Accessed 20 December

2018].

World Health Organisation (WHO). 2016a. Health Infrastructure - Data by country. [ONLINE]

Available at: http://apps.who.int/gho/data/view.main.30000. [Accessed 20 December 2018].

World Health Organisation (WHO). 2016b. Countries, Slovakia. [ONLINE] Available at:

http://www.who.int/countries/svk/en/. [Accessed 20 December 2018].